This week the Centers for Medicare & Medicaid Services approved New Hampshire’s bid to impose work requirements on Medicaid recipients, becoming the fourth such state under new guidelines issued at the beginning of the year by the Trump Administration. Kentucky, Arkansas, and Indiana have also received approval to add work requirements, while applications are pending in six additional states: Arizona, Utah, Kansas, Mississippi, Wisconsin, and Maine.

These types of waivers, which fall under Section 1115 of the Social Security Act, are supposed to give states the flexibility to test local approaches that may differ from federal Medicaid rules, but share the goal of advancing the overall aims of the Medicaid program. States have used them for a variety of purposes in the past, including implementing systems of managed care, expanding coverage to non-traditional Medicaid populations, and extending health care coverage during an emergency. Under the newly approved waivers, Medicaid recipients will be required to work or participate in “community engagement” activities (including job training, caregiving, or volunteering) for 20 hours per week. Those who are pregnant or have disabilities would be exempt. In some states, such as Kentucky, the work rules would only apply to the population that receives Medicaid under the expanded eligibility rules of the Affordable Care Act. In other states, notably Kansas, the rules would affect all beneficiaries, including those who are very poor. Other states have Section 1115 waivers pending to require drug testing for Medicaid recipients, impose lifetime limits on coverage, and impose premiums with disenrollment for nonpayment; such waivers have never been approved, but that may change in the current political climate.

Since the Trump administration took office in 2017, the Centers for Medicare & Medicaid Services have altered the criteria for considering Section 1115 waivers. In 2015, during the Obama years, the language focused on increasing and strengthening coverage and health outcomes for low-income individuals and improving provider networks for Medicaid beneficiaries. By November 2017, the guidelines had been revised to underscore new priorities: “responsible decision-making,” “upward mobility,” “greater independence,” and “strengthen[ing] beneficiary engagement in their personal healthcare plan.”

This language of empowerment reflects a fundamental shift in ideology, from providing crucial health coverage to a disadvantaged population to trying to ensure that people are not, as the saying goes, “getting something for nothing.” The new guidelines glorify the idea of work for work’s sake, linking employment with increased income and better health outcomes, while decrying what CMS director Seema Verma has called “the soft bigotry of low expectations” that keeps people trapped in poverty. Critics have pointed out that nearly 60 percent of non-disabled Medicaid recipients who are able to work already do; imposing work requirements will do nothing to create jobs, and will simply enact punitive measures on those who do not have them. The burden of reporting one’s work hours weekly will create additional hurdles for Medicaid recipients, many of whom already face multiple challenges, while the increased administrative costs may not result in any savings for state and local governments. The new requirements don’t account for those with unstable and unpredictable hours, who may average 80 hours per month but work fewer than 20 hours during some weeks. Moreover, losing one’s health insurance could make it more difficult for someone to find and keep a job. It’s not much of a surprise that an individual with steady employment will have more income, be healthier overall and less likely to suffer from depression than someone who is unemployed. But it’s not at all clear that work itself always produces these results, or if those who are healthier overall are also better equipped to find and keep such jobs.

Previous administrations have rejected Section 1115 waivers that were not consistent with the original aim of the Medicaid program, which is to expand medical coverage to eligible populations. The new work requirements, which will reduce Medicaid rolls by making it harder and more onerous for people to keep their coverage, clearly conflict with this goal. In approving the requirements, the Center for Medicare & Medicaid Services is defining health care as something that must be earned through a display of worthiness. It imposes a moral imperative on the provision of health care, forcing recipients to prove their fitness to receive government benefits by behaving in ways that are state-sanctioned: working, not doing drugs, demonstrating personal responsibility. The underlying (and familiar) assumption is that poverty is a behavioral issue that can be fixed by punishing abnormal comportment. But the problem is far deeper and more complicated. Medicaid work requirements are both overly punitive and a result of faulty logic. Making it more difficult for low-income individuals to maintain health coverage will not solve poverty. Instead, it will increase inequality, further disadvantage an already vulnerable population, and endanger public health.